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An ethnographic study exploring the role of wardbased Advanced Nurse Practitioners in an acute medical setting
Williamson, Susan, Twelvetree, Timothy, Thompson, Jacqueline and Beaver, Kinta
Available at http://clok.uclan.ac.uk/5577/
Williamson, Susan ORCID: 0000000296354473, Twelvetree, Timothy, Thompson, Jacqueline and Beaver, Kinta ORCID: 0000000265522323 (2012) An ethnographic study exploring the role of wardbased Advanced Nurse Practitioners in an acute medical setting. Journal of Advanced Nursing, 68 (7). pp. 15791588. ISSN 03092402
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An ethnographic study exploring the role of ward-based
advanced nurse practitioners in an acute medical setting
Journal: Journal of Advanced Nursing
Manuscript ID: Draft
Manuscript Type: Original Article
Keywords: Advanced Practice, Ethnography, Skill mix, Clinical Nurse Specialist, Holistic Care
Category: Nursing
Journal of Advanced Nursing
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An ethnographic study exploring the role of ward-based advanced nurse practitioners in
an acute medical setting
ABSTRACT
Aim. This paper is a report of a study that aimed to examine the role of ward based
Advanced Nurse Practitioners (ANP) and how they impact on patient care and nursing
practice.
Background. The international impact of revised doctor/nurse skill mix combined with a
focus on improving quality of care whilst reducing costs has altered the pattern of
healthcare delivery. The diversity and implementation of advanced nursing practice roles
has developed globally over the last decade. However, the role and expectations for ward
based ANPs lacks clarity, which may hinder effective contribution to practice.
Methods. This study used an ethnographic approach to explore the ANP role. This included
participant observation of five ward based ANPs working in a large teaching hospital in the
North West of England during 2009, complemented by interviews with ANPs, 14 ward
nurses and five patients. Data were descriptive and broken down into themes, patterns and
processes to enable interpretation and explanation.
Results. The overarching concept that ran through the analysis of data was that of the ANP
as a lynchpin, using their considerable nursing expertise, networks, and insider knowledge
of health care systems not only to facilitate patient care but to develop a pivotal role
facilitating nursing and medical practice. Sub-themes included enhancing communication
and practice, acting as a role model, facilitating the patients’ journey and pioneering the
role.
Conclusion. Ward based ANPs are pivotal and necessary for providing quality holistic patient
care and their role can be defined as more than junior doctor substitutes.
Key words: advanced nurse practitioners, specialist nurses, skill mix, ethnography,
participant observation
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Summary Statement
What is known
• The role of Advanced Nurse Practitioners (ANP) in practice is not clearly defined.
• A lack of role definition and management support causes barriers to advanced
nursing practice.
• ANPs can undertake some of the role of junior doctors.
What this paper adds
• The role of the ward based ANP is pivotal to the management and delivery of quality,
holistic patient care.
• ANPs are highly valued in a ward setting as they are accessible and provide an inter-
professional communication channel, a technical and knowledgeable resource, and
continuity of care.
• ANPs perceive inadequacies in their educational preparation.
Implications for Practice and/or Policy
• Ward based ANPs could improve the response to Early Warning Score (EWS) triggers.
• Ward based ANPs are believed to have a positive impact on length of patient stay
and discharge procedures.
• Further work is needed to evaluate the impact of ward based ANPs on admissions to
High Dependency or Intensive Care Units (HDU/ICU)
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INTRODUCTION
The diversity and implementation of advanced nursing practice roles has developed globally
over the last decade, often in response to localised initiatives based on revised doctor/nurse
skill mix (Ball & Cox 2003, Bryant-Lukosius et al 2004, Buchan & Calman et al 2005, Gardner
et al 2007). A reduction in junior doctors working hours and more structured supervision
requirements for training spurred the development of more specialist and advanced nursing
roles, which equipped nurses to take on many procedures and tasks traditionally associated
with junior doctors (NHS Executive 1991, Cox 2001). Advanced nursing practice creates
enhanced levels of competency with a positive impact on patient care; higher levels of
educational preparation impact on patient mortality and patient satisfaction (Aiken et al
1994, Clarke & Aiken 2003, Rothberg et al 2005). However, there is much confusion about
variability in nursing roles, titles, and expectations (Ball & Cox 2004, Bryant-Lukosius 2004,
Laurent et al 2009). To date there has been no investigation of the actual, rather than
theoretical or perceived role, of ward based Advanced Nurse Practitioners (ANP) and their
potential impact on patient care and nursing practice. This study aimed to address this gap
in knowledge, using ethnographic techniques to identify and clarify the role and impact of
ward based ANPs in a large teaching hospital in the North West of England.
BACKGROUND
The term “advanced nursing practice” encompasses many specialist roles within nursing but
does not define them and in developed English speaking countries, particularly Australia,
Canada, the United Kingdom (UK) and United States (US) has led to the term being used to
describe specialist nursing roles with a wide variation in scope of practice and educational
qualifications (Aiken et al 1994, Mundinger et al 2000, Ball & Cox 2003, Bryant-Lukosius et al
2004, Gardner et al 2007, Gardner et al 2008, Pulcini et al 2009). In the US and UK, nurses
with advanced practice skills were originally employed in primary care to ease General
Practitioners (GP) workload and to provide enhanced primary care services (Brown &
Grimes 1995, Mundinger et al 2000, Horrocks et al 2002). However, it is not clear what
added value these highly skilled and trained nurses bring to secondary care.
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Recent studies have attempted to distinguish the often subtle difference between nurses in
advanced nursing practice roles such as ANPs and Clinical Nurse Specialists (CNS). A CNS
uses advanced nursing skills within a given specialist area while an ANP works across
specialism’s in much the same way as junior doctors (Gibson & Bamford 2001,Austin et al
2006, Gardner et al 2007, Mitchell et al 2010). It is interesting that the use of ANPs has been
largely confined to specialist areas, as the reduction in junior doctors hours in the UK
affected all areas of patient care including general in-patient wards. It is argued that ANPs
have not just filled the gap left by a reduction in junior doctors’ hours, but also use their
expertise to identify and fill gaps in service provision (Ball & Cox 2004, Gardner et al 2008,
Laurent 2009).
Whilst the experience and skills of ANPs can be used to define many of the characteristics of
advanced nursing practice, capabilities go beyond these competencies to include high levels
of self efficacy, creativity and innovation in complex situations while working effectively as
part of multidisciplinary teams (Gardner et al 2007, Gardner et al 2008, Pulcini et al 2009).
Additional training and education enable ANPs to perform patient consultations, physical
examinations, arrive at a differential diagnosis and prescribe where appropriate. However,
on an international level it is evident that hospital based ANPs are often appointed,
educated and trained without clear definition of what their employers expect of them (Ball
& Cox 2004, Bryant-Lukosius et al 2004, Buchan & Calman et al 2005 Garner et al 2008).
In spite of studies identifying what the role of ANPs should be and what ANPs are able to do,
there is little evidence describing what ANPs actually do to fulfil their role and how this
impacts on nursing practice and patient care (Ball & Cox 2003, Bryant-Lukosius et al
2004,Lloyd-Jones 2005, Gardner et al 2007, Gardner et al 2008, Mitchell et al 2010). This
study aimed to examine these issues.
AIM
To examine the role of ward based ANPs and how they impact on patient care and nursing
practice.
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METHOD
Design
A qualitative ethnographic design was chosen using non-participant observation and semi-
structured interviews. Ethnography explores people’s behaviour in a natural rather than
contrived setting in order to interpret and explain behaviour in the context of the rules,
roles and expectations of culture (Fetterman 1989, O’Leary 2004, Hammersley & Atkinson
2007). Observation in a health care setting allows the collection of naturally occurring data
and events that are often taken for granted without causing disruption or interruption. It
enables the identification of the context in which events happen and examines associations
between events and the effectiveness of the actions of the participants (Ritchie & Lewis
2007). Although individual in-depth interviews are time consuming they complement the
observation and are a key part of the interpretation of observed events (Spradley 1980).
Interviews allow participants to provide their own interpretation of events and describe
personal feelings about experiences within their position in a particular environment.
Participants
Study participants were recruited in two stages. Initially the practice of five ANP’s employed
on acute medical wards at a large teaching hospital in the North West of England was
observed. Direct observation was considered essential in gaining a full understanding of
how ANPs function and communicate in clinical reality as perceived action and actual action
may differ. Following the observation interviews were conducted with all five ANP’s, a
sample of 14 ward nurses, stratified by job title, and five patients.
Data Collection
Observation
Prior to commencing the formal observation period, time was spent meeting the ANPs’ and
shadowing them on the wards to acclimatise them to the study and minimise any distortion
that the observation may have. Subsequently each ANP was observed over seven days for
between two to three hours each day on different shift patterns until both they and the
researcher felt that the observation period had covered an accurate representation of their
practice. Detailed notes were made about what and who was being observed, the physical
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setting, interactions and activities, including significant quotes from informal opportunistic
interviews with a number of health care professionals including medical consultants, junior
doctors, nurses, physiotherapists, occupational therapists and clinical pharmacists. This
enabled the observations to be reviewed away from the clinical setting and later during
analysis. Notes were taken after each observation period as overt note taking during
observation could have been perceived as threatening and disruptive (Hammersley &
Atkinson 2007). Eighty six hours of observation were completed. The observation generated
questions, some of which were addressed during informal interviews and others were used
to inform interviews.
Interviews
The five ANPs, 14 ward based nurses and five patients were invited to participate in
interviews; time constraints and a change in discharge policy hindered the recruitment of
more patients. A diverse range of views were sought from both junior and senior ward
nurses. Patients were interviewed at the point of discharge, allowing time to form an
opinion about their hospital stay and those who cared for them. Issues that had arisen
during observation were integrated into all the interviews (Fontana & Prokos 2007). The
ward environment in which each ANP worked was very different, so individual interviews
with ANP’s provided an understanding of their feelings about, and interpretation of, their
role. They were asked to comment on their perceptions of their role and communication
patterns with other health professionals. Ward nurses were asked what they liked and
disliked about working with an ANP, the role of an ANP and whether ANP’s had an impact
on patient care and nursing practice. Patients were asked more general questions about
their stay on the ward, how they felt about their nursing care and information given to them
about their condition. With consent, all interviews were recorded and transcribed.
Ethical considerations
Ethical approval was granted by the National Research Ethics Service for England and by the
Research and Development Department at the study site. Although ANP’s were the focus of
observation, other ward staff and patients were present during periods of observation.
Therefore, the consent of each ward manager was sought to allow the presence of the
researcher in ward areas. All participants, including patients, consented in writing and
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confidentiality was protected through the use of identification numbers and the removal of
all identifying features from the data.
Analysis
Field notes contained the reactions and reflections about the significance of the processes
observed. As insights and ideas became apparent they were annotated and formed part of
the preliminary analysis of what had been observed. The purpose of the observation was to
describe and explain the observed role of the ANP and data were broken down into the
concepts, patterns and processes that enabled interpretation and explanations. A second
researcher read and annotated the field notes and developed concepts which were then
compared and discussed (Spradley 1980, Hammersley & Atkinson 2007).
Transcripts of interview data were read and open coded independently by two researchers.
A framework was developed and the coding re-examined using content analysis. As patterns
and themes emerged, categories were identified and comparisons made with the data and
preliminary analysis from observations. Any discrepancies were resolved through review
and discussion. Reliability was established through the above processes. When analysis was
completed the preliminary findings were shown to the ANPs and ward nurse participants to
ensure that views and events were reported accurately, thus assisting the validation process
(Spradley 1980, Hammersley & Atkinson 2007).
RESULTS
Participant characteristics
ANP participants included two males and three females; all had attained a Masters degree
in advanced nursing practice and were experienced nurses having previously worked as
senior nurses or CNS’s in a variety of clinical settings but not on acute medical wards. All had
been in post for about two years and reported that their role was still developing. All 14
ward nurses were female registered nurses, including four ward managers, three ward
sisters (registered nurses with a clinical and managerial role), four staff nurses (registered
nurses with a clinical role) and three assistant practitioners (nursing assistant with
vocational qualifications). Of the five patients, four were female and one was male.
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Key themes
The overarching concept that ran through the analysis of data was that of the ANP as a
lynchpin, ensuring effective communication between those providing, and those receiving,
patient care to ensure a quality service. A number of sub-themes emerged from the
observation and interview data: enhancing communication and practice, acting as a role
model, facilitating the patients’ journey and pioneering the role (Figure 1).
ANP as a lynchpin
A number of roles and skills were observed, with ANPs’ facilitating most aspects of patient
care. After initial scepticism from medical consultants, they described ANPs as “pivotal”, and
an invaluable link between medical and nursing teams. ANPs shared responsibility for
patients with junior doctors, playing an active part in consultant’s ward rounds and, because
they were ward based, provided a continuity that junior doctors could not. Their specialist
knowledge, technical skills and clinical judgement were respected and their sustained
presence on the ward enabled a detailed understanding of each patient’s history and
circumstances, which was used to expedite early discharge. All ANPs acknowledged that
they were an information and communication resource for a diverse range of health care
professionals involved in patient care. All grades and types of staff were observed
approaching ANPs to ask questions about individual patients’ condition, diagnosis and
treatment.
“ Not only does she help with the doctors jobs or the nurse's jobs, she is kind of a link. You
know like a bridge between doctors and nurses.” (ID77 Staff Nurse)
“ I've had quite a lot of tests .... They do explain to you what they're for, and they do give you
printed information...They will all reassure you, but I think the one that will tell you
everything about it would be your advanced, because [ANP name]... I think knows more,
because he is advanced, ....” (ID 78 patient)
Ward nurses reported that ANP’s had a positive impact on nursing practice but considered
ANPs to be more closely allied to the medical rather than nursing team. They all agreed that
ANPs assisted with nursing work but on the whole felt that they did not actually do any
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“hands on” nursing. However, this view was not shared by ANPs who felt their role enabled
them to spend more time practicing nursing.
“I believe I nurse better as an advanced nurse practitioner than I had the opportunity to as a
sister in charge of a busy high dependency unit. And what I mean by that is I have the time
to sit down alongside a patient and explain things to them, and listen to them. And that’s
something I really struggled to do in my previous nursing roles, because of other demands on
me.” (ID60 ANP)
Enhancing communication and practice
The ANPs were observed to be experienced confident practitioners using subtle and
complex communication skills which the younger nurses and doctors had not yet developed.
In addition ANPs frequently ‘translated’ medical instructions for nurses, patients and allied
health professionals, to ensure that the significance of planned care was understood. ANPs
often returned to patients after a ward round to ensure that they understood what had
been said, providing further explanations if necessary using different vocabulary.
“And the fact that [name ANP]understood. He just hit the nail right on the head, and took
time, oh he was in here for a long time. But he waited, and kept going until he was satisfied
that I was quietly confident and I was reassured enough”. (ID78 patient)
Nurses generally found ANPs less intimidating and more approachable than doctors when
resolving care issues. Having an ANP available as a resource inspired confidence as nurses
felt they always had back up and support. In addition, the ANPs proactive approach meant
that they picked up on issues that needed to be addressed to prevent patient deterioration
or delayed stay.
“… it's having the back up there, that we know as staff nurses that... what we're supposed to
do. But having the ANP there as well she overlooks the obs [observations] on the ward
round, and then picks up on anything that was sort of perhaps missed or not undertaken. So
it's... Having them there as an added back up really.” (ID68 Staff Nurse)
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Role model
In addition to formal teaching and mentorship, ANPs used their technical knowledge and
skills to provide informal support and teaching to nurses and junior doctors. This promoted
ANPs as role models, which they embraced and appreciated.
“I’m a resource for them.… I’m a member of the team that the majority of nurses don’t feel
disinhibited in approaching …So it’s what learning opportunities I can then create within that
interaction for them”. (ID60 ANP)
The ANPs’ familiarity with the hospital and their networking skills brought advantages. All
the ANPs’ were observed supporting and teaching junior doctors when they first started on
the wards and were unfamiliar with the organisation. ANPs reported that part of their role
was to support and guide junior doctors to enable them to be more efficient whilst they
were still familiarising themselves with the hospital systems.
“Well I hope they (junior doctors) see it as helpful. They tell me that they do so… Especially
at this time of year, the doctors… But I like that, I like being useful so it’s… I like this time of
year, ‘cos there’s always lots of questions, and not just about what’s going on with the
patients, just general systems within the hospital and that sort of thing… I feel like mother
hen gathering them all up and leading them along.” (ID66 ANP)
Occasionally it was observed that having an ANP on the ward seemed to reduce the need
for ward nurses to use their initiative and develop their skills. ANPs reported that although it
was flattering when ward nurses assumed they would always have answers to their
questions, it reduced the need for them to use their analytical skills. De-skilling, therefore,
was a possibility, particularly on a busy ward where time was limited.
“And I'm so reluctant to say this, because I'm so grateful for everything [ANP]'s done, if
anything he might slightly de-skill me, in that I think oh, that's a difficult blood, I'll ask him to
take it. Oh, that's a difficult procedure, but [name ANP]'s here. Whereas if he wasn't I would
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be in a position where I would have to try myself. So I don't know if that slightly de-skills
me... (ID 74 Ward Sister)
Facilitating the patients journey
ANP’s were observed as pro-active rather than reactive in providing and enabling holistic
care for patients. They anticipated what would be needed and actively tried to improve the
speed at which tests and investigations were expedited and referrals acted upon. As ANPs
were accessible, ward nurses were able to utilise their technical skills and knowledge with
immediacy rather than waiting for a junior doctor, which speeded the response to patient
needs or deterioration.
“I think I have a crucial impact on the care that they receive, because not only am I involved
in their medical management and chasing up appropriate investigations and reviewing them
daily, I’m also ensuring that from a nursing point of view that the care that they’re receiving
is appropriate,... and that the nursing staff are aware of warning signs when they’re
becoming acutely unwell, and who to refer onto...... So I’m not only thinking about their
aetiology at the time, and managing that, I’m thinking about their emotional needs and I’m
thinking further ahead from that, I’m thinking well when we get to the point of them being
medically fit how are they gonna manage at home, what do we need to be doing now in
order to get all this process sorted out for that long-term vision if you like”(ID65 ANP).
A rapid response to patient deterioration was highly valued; patients who may otherwise
have “triggered” on the early warning score (EWS) system were subject to prompt
intervention by an ANP. Nurses reported that ANPs had enhanced credibility; if the ANP
asked one of the doctors to come to the ward to see a patient who was triggering on the
EWS they would not be ignored, which again enhanced the care that the patients were
given.
“ANP can deal with the situation immediately, and her ringing the doctors to come to review
the patient, they will come much quicker than they will with the nurses on the ward ringing
to...And usually she's done everything anyway in preparation, she's done all the blood tests,
she's done the ECG, she's ordered chest X-ray, put a drip up, so all those things have usually
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been done before the doctors actually get to the ward... you're not wasting as much time.”
(ID72 Ward Manager)
Pioneering the role
ANP’s were observed to be consummate professionals but interviews identified a number
of challenges they had faced, indicating little clarity around role expectation or scope of
practice. They had to overcome initial scepticism from other health professionals, carve out
a role and integrate themselves into the medical and nursing teams on the wards where
they were based. The ANP’s perceived that they were neither part of the medical or nursing
team, yet had to meet competing demands and, in some cases, overcome the antagonism
of colleagues.
“I was told a couple of months in to the job, that the consultants didn’t want an ANP... They
didn’t understand what it was, but they didn’t want one. ” (ID 66 ANP)
“The inherent challenge of an advanced nurse practitioner is to meet everybody’s competing
demands, because everybody’s got a view on what you should be doing. Nurse management
have their perspective. The medical team will come with their views and so on and so forth.
But somewhere along the line you’ve got to carve out something that’s whilst it meets the
operational expectations and demands of the trust [hospital], it’s also satisfying...” (ID60
ANP)
Many senior nurses expressed initial misgivings about working with an ANP as they
expected some degree of role conflict with concern that ward nurses would be de-skilled as
ANPs undertook many of the extended roles that senior nurses had previously undertaken.
As a result, ANPs had to find a niche in which to develop their role and prove their sceptics
wrong. Each role, therefore, was individually developed by each ANP and it was interesting
to note that ANPs expressed a lack of knowledge regarding each others role.
ANPs reported that their Masters degree in advanced nursing practice had not adequately
prepared them for their clinical role and they were ill prepared in terms of communication,
political awareness and leadership skills. However, as one ANP conceded, how can one
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prepare for something that is not defined? When reflecting back to their initial
appointment as ANPs, the primary need was to practice at a high level within a clinical
reality that could not be prepared for through academic study alone. ANPs placed a high
value on the clinical teaching and support provided by consultant physicians.
“Educationally it’s a very intense rushed course really and there’s a lot of… Well I didn’t feel
it was enough. We seemed to rush through each system. ......And compared to the junior
doctors we don’t get the background that they get, and yet we’re expected to do some of the
things that they do. Your nursing background will fill in some of the gaps, but I didn’t feel
adequately educationally, clinically trained for the role. (ID66 ANP)
DISCUSSION
The National Health Service (NHS) management in the UK have called for clear role
definitions and role expectations as they strive to improve the quality and value of care for
NHS patients (DoH 2010, NHS Institute 2011). The findings from this study confirm that ANP
roles are not clearly defined and variation in roles and inconsistent expectations can result
in possible role conflict, variable acceptance and role overload (Griffin and Melby 2005,
Bryant-Lukosius et al 2004). This study noted variability in roles within one study location.
This individualisation makes evaluation and comparisons between ANPs challenging and
highlights the importance of ethnographic research to highlight similarities and differences
in roles, experiences and expectations. However, in this study there were key roles and
associated common tasks which situated ANPs as lynchpins in the wards on which they
worked. Figure 2 aims to assimilate these roles and tasks to give an overview of role
expectation that may be useful for health care providers when developing job descriptions
and person specifications for advanced nursing roles. However, it is acknowledged that
providing such structured definitions of expectations could raise tensions between the
desire to see roles more formally defined and the professional autonomy an ANP role
brings.
It could be argued that role uncertainty and a lack of clarity of roles is an inevitable
consequence of increasing specialisation in the nursing profession. However, the
interpretive nature of new roles and responsibilities in advanced nursing practice, such as
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ordering and interpreting diagnostic tests and prescribing, is important for ANPs in relation
to future role development (Lloyd Jones 2005, Griffin and Melby 2006). The ANPs in this
study expressed the view that their Masters degree had not adequately prepared them for
their clinical role, perceiving that too much emphasis was placed on academic, rather than
the practical skills required for their role. It has been reported that nurses in transition to
ANP roles are more likely to place priority on development of clinical skills rather than
broader skills such as research, audit and supervision (Griffin and Melby 2006, Woods 1998).
Griffin and Melby (2006) argued that Masters education should “ensure that ANPs have the
clinical and theoretical knowledge that is fundamental to satisfying core concepts of the
role” (Griffin and Melby 2006: p299). A systematic review of role development and
effective practice in specialist and advanced practice roles in acute hospital settings
reported that characteristics required for effective ANP working included confidence,
adaptability, negotiating skills, political astuteness and motivation and creativity (Lloyd
Jones (2005). However, these were the skills that ANPs in this study reported as missing
from Masters courses; skills that they had to learn on the job. However, a vicious circle is
evident here; how can an ANP be prepared for a role that has not been clearly defined?
Results from this study may assist in providing a definition and framework to help
educationalists focus courses to better prepare ANPs for the clinical workplace.
All grades of staff involved in patient care clearly respected and valued the clinical
judgement of ward based ANPs. Their knowledge and skills enabled them to work across
specialist boundaries in a similar way to junior doctors, yet they were perceived as more
useful as a result of their accessibility, approachability and enhanced technical and
communication skills. The ward nurses recognised the ANPs role in expediting patient care
and acknowledged a perceived speedier reaction to patient deterioration and corresponding
reduction in admissions to the Intensive Care Unit (ICU). However, this study did not seek to
evaluate the impact on outcomes of the ANP role and we do not have data on whether
admission rates to High Dependency Units (HDU) and ICU had reduced since ANPs
commenced in post. If this data were available it would be speculative to suggest a causal
link between ANP presence and rapid response to EWS triggers and/or reductions in
admissions to HDU/ICU. This warrants further investigation as the response to critically ill
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patients relies on nurses recognising signs of deterioration and reporting them
appropriately (Clarke & Aiken 2003, Rothberg et al 2005, NICE 2007).
This study shows that ward based ANPs play a pivotal role in the patients’ journey by
providing a communication channel between doctors and nurses, between doctors and
patients as well as being an information resource. The introduction of ANPs was viewed by
many as a way to reduce work pressure on junior doctors. A question remains whether the
NHS and the associated professions are able or willing to continue with this development.
Despite the favourable view, and central position of ANPs to patient care in England, acute
sector medical and nursing budgets are distinct. If the contributions of ANPs to reducing
medical workload are not recognised in a financial way within nursing budgets, there could
be concerns that the enthusiasm of nurse managers to support these relatively high grade
positions is not sustainable and may not be maintained. Especially as this study
demonstrates that although nurses attributed advanced nursing skills such as “knowing” the
patients, proactive care, developed recognition skills and effective communication to the
ANPs they did not acknowledge these skills as “nursing” and viewed ANPs as being more
closely aligned to medicine (Benner & Tanner 1987, Castledine 1991). This study is timely,
given the downturn in the global economy and subsequent impact on health care spending.
Further work is needed to assess the impact of ward based ANPs on response to EWS
triggers, patient length of stay and the corresponding economic impact on patients and
health care systems (Rothberg et al 2005, Clarke & Aiken 2003,NHS Institute 2011). This
study is limited by the small numbers of ANPs and one study site. However, it can be
suggested that ward based ANP roles should aim to improve and develop nursing and
medical practice for the benefit of patients by challenging traditions that are not evidenced
based, enhancing communication between health care professionals and patients, pro-
actively co-ordinating and facilitating patient investigations, diagnoses, and subsequent care
and treatment plans, and act as a resource, role model and mentor to nursing and medical
colleagues. Clarifying role expectations should improve preparation and efficiency and go
some way to eliminating the challenges and confusion surrounding ANPs.
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Conclusion
This study achieved its aim of identifying the impact of ward based ANPs on nursing practice
and patient care and describing their role. Moreover it shows that ward based ANPs use
their considerable nursing expertise, networks, and insider knowledge of health care
systems not only to facilitate patient care but to develop a pivotal role facilitating nursing
and medical practice. In addition this study demonstrates that because of their nursing
heritage, increased skills and knowledge, ward based ANPs are more than junior doctor
substitutes.
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Figure 1. Key themes and sub-themes
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Figure 2. ANP role description
Role Tasks
Facilitate every aspect of patient’s care
• Patient advocate
• Facilitate prompt investigations, using networks
• Order, undertake, interpret, follow-up on diagnostic tests
and investigations.
• Prescribe, checking alter prescriptions
• Problem solving clinical and patient-based issues.
• Conducting/participating in Ward Rounds
• Conducting patient reviews/examining patients
• Referring patients for specialist medical and nursing
opinion
• Discussing treatment plans with nurses, doctors, AHPs
and clinical scientists e.g. pharmacists, radiographers
to ensure rationale understood Ensure patients have
medical reviews
• Actively involved in MDT(multidisciplinary team) meetings
• Facilitates/drives discharge/referral process
Role model
• Provides advice, knowledge and support to medical,
nursing, and other staff
• Formal and informal teaching of medical and nursing staff
• Literature searching in support of teaching duties or
practice development
• Attend study days/do audit/research/evidenced based
practice/care pathways
• Admin duties/meetings
Ensures continuity of care
• Ward based Monday to Friday
• Follow-up on ward round actions
• Identify anything missed or not undertaken following ward
round
• Driving discharge/referrals
• Check/follow up on patients triggering EWS
• Liaising with AHPs health and clinical scientists
Resource for nurses, junior doctors
AHPs and clinical science staff and
patients
• Plans care – ensures team approach of all involved
• Prevents delays in treatment/discharge
• Ensures continuity of care
• Ensures provision of holistic care
• Provides cover for doctors
• Share ward round with doctors
• ‘Translates’ medical language into understandable terms
for nurses, AHPs and patients
• Responds to patient and relatives requests and queries.
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